Hitting the Wall: The Cycles, Studies, and Treatments of Addiction

Lauren DoughertyLeah Olson

The Feeling Brain 21 December 2012

“Drug addiction is a mental disorder characterized by the compulsive use of drugs that

persists despite awareness of negative consequences” (Bechara & Naqvi 2008). The study

of addiction has, in the past century, become an ever-evolving and expansive field of

research. The realities of addiction are much deeper, much darker, and much more

complex than even current research can entirely explain.

“The addictive experience is characterized by intensity of feelings which cannot

be rendered symbolically via language. Out of this mode of experiencing emerges

three phenomena: 1) an alteration in the sense of the movement of time; 2) a sense

of alienation and lack of sense of connection to others; 3) a lack of sense of

agency in the world and inability for self-affect regulation” (Hopson 1993).

The body of this paper is an investigation of the colloquial, psychological, and neuro-

scientific understanding known as “hitting the wall” or “rock bottom” within the realm of

addiction. Even still, “No simple method is appropriate or effective for treating all

individuals” (Hoffman et al. 2007). An initial indicator of just how elusive and complex

addiction truly is can be seen in the widely varying types of treatments available to

“cure” addiction. Despite the newly developed successes of “Multi-Pronged” and

“Dynamic Psychotherapy” approaches, experts now maintain that an addict usually needs

to relapse at least once after initially engaging with therapy, and usually has three to four

false starts, in order to become truly committed to quitting and complete a full year of

sobriety (Hoffman et al. 2007). This approach has affected all practices of therapy by

encouraging an understanding of the function of the brain systems throughout the

addiction and. Nora D. Volkow, MD, Director of the National Institute on Drug Abuse,

explains that the addicted brain is not a matter of willpower—something many loved

ones of addicts, and society as a whole, often fail to see. This characterization of

addiction as a ‘willpower problem’ is an old belief, probably based upon wanting to

blame addicts for using drugs to excess. This myth is reinforced by the observation that

most treatments for alcoholism and addiction are behavioral therapies, which are

perceived to build self-control. However, addiction mostly occurs in an area of the brain

called the mesolimbic dopamine system that is not under conscious control. However,

though the mesolimbic dopamine system underlies the core of the neurocircuitry that

perpetuates addiction, other brain systems have been found to also contribute to the

addiction process (Bechara & Navqi 2008).

“We depend on our brain’s ability to release dopamine in order to experience

pleasure and to motivate our responses to the natural rewards of everyday life,

such as the smell of food. Drugs produce very large and rapid dopamine surges,

and the brain responds by reducing normal dopamine activity. Eventually, the

disrupted dopamine system renders the addict incapable of feeling any pleasure—

even from the drugs they seek to feed their addiction. Even though the drugs have

lost their power to reward, the altered brain regions that attempt to control

decision-making and judgment are still processing desires and emotions. The

resulting lack of control leads addicted people to compulsively pursue drugs”

(Hoffman et al. 2007).

Evidence further indicates that alcohol, cocaine, and opioids—drugs that are widely

regarded as addictive—lead to compulsive drug-seeking behavior, impaired self-control

over drug intake in a significant proportion of users, acutely depressed prefrontal cortical

activity and, at least in the case of alcohol and cocaine, produce impairments on

neuropsychological tests that are sensitive to frontal lobe functioning (Lyvers 2000). In

any case, if the prefrontal cortex mediates the process that have been variously termed

autonomy, volition, and self-control, then drug-induced impairment of such frontal lobe

executive functions may plausibly account for the disinhibition and other behavioral

changes associated with acute intoxication, as well as contributing to more chronic

problems such as impulsiveness, inflexibility, perseveration, denial, and difficulties with

self-control described in alcoholics and other addicts (Lyvers 2000). The likelihood of

acute and/or chronic frontal lobe deficits in addicts has significant implications for

addiction treatment and relapse prevention methods, as has been previously discussed by

several other authors (Lyvers 2000). Even still, more than 80% of addicted individuals

fail to seek treatment at all, which might reflect impairments in recognition of severity of

disorder. Considered by some as intentional deception, such ‘denial’ might instead reflect

dysfunction of brain networks sub-serving insight, and self-awareness. “Among these

networks, abnormalities in the insula and medial regions of the pre-frontal cortex, which

include the anterior cingulate and mesial orbitofrontal cortices, and in subcortical regions

including the striatum have been highlighted when studying drug-addicted individuals”

(Goldstein et al. 2009). In addition, it has been shown that a high level of activity in the

insula during a simple decision-making task is associated with relapse to

methamphetamine use, indicating that dysfunction of the insula underlies some of the

abnormal decision making that leads to continued drug use in the face of negative

consequences” (Bechara & Naqvi 2008).

It is easy to see then, that putting an end to addiction is no easy task. Every method,

however comprehensive or different from one another, pursues aspects of an addicted

individual’s character hoping to motivate change within that individual’s lifestyle. Most

behavioral therapies use shame, guilt, or sadness as a motivator with which the individual

can associate their harmful behavior (Greenberg & Pascal-Leone 2007). This is known

colloquially as “hitting rock bottom”, and the association to their current destructive

behavior to the lowest, saddest, or most life-threatening point in their existence allows an

addicted individual to place themselves, mentally, on a path in which the only direction to

move is up, or towards recovery.

What makes shame and guilt particularly potentially successful is these emotions ability

to remain poignantly intact as emotional states, despite the altered dopamine system of an

addict’s brain. This use of “Emotional Processing” is one of the newest forms of therapy,

and is a vein of psychotherapy that originated from experimental research which

concluded, “when it comes to recovering from dysphoria, the only way out is through”

(Hunt 1998). Emotional processing provides a general framework for how emotional

change occurs through the interpersonal tasks described in emotion-focused therapy

(EFT), and emotion has been championed in recent years as playing a crucial role in the

process of self-motivated client change in several major approaches to therapy

(Greenberg & Pascal-Leone 2007). In their study of “moment-by moment emotional

processing” Greenberg and Pascal-Leone formulate a specific model of how experiencing

emotion actually changes people—or how “emotion changes emotion” to ask the

question: How do clients process highly aroused states of negative feeling? Both based

on clinical theory and practice, they proposed a model for the restructuring of what they

referred to as “bad feelings”. The model of client processes reflects the treatment steps

for evoking, exploring, and restructuring unhealthy emotion. In the context of addiction

recovery, this is powerful step towards uncovering the dysfunctional roots of why addicts

continue to use. The essence of Greenberg et al.’s model takes the aroused negative states

such as shame and guilt brought on by abusing a substance, for example, and manipulates

them to create a healthy state of being within the client, where they no longer feel the

need to abuse drugs.

“Restructuring bad feelings begins with attending to the aroused feelings followed

by exploring the cognitive-affective sequences that generate those bad feelings.

Eventually this leads to the experience of the output of some maladaptive emotion

scheme. Often, this is a form of fear, guilt, shame, or sadness that represents an

unhealthy and painful way of perceiving and experiencing oneself: one that is

regrettably familiar to the client, like an age-old emotional wound. In short, the

essence of emotional reorganization is the creation of some healthy emotional

alternative in the face of dysfunctional feeling and belief—involving moving from

visceral, somatic experience of core affect with defense, anxiety, or shame”

(Greenberg & Pascal-Leone 2007).

This exploration of the cognitive fusion of highly aroused states with an incomplete

evaluation of the self is a key element of many therapies. Acceptance and Commitment

Therapy targets shame with respect to substance use disorders. Shame has been relevant

to substance use disorders and their treatment, but the precise nature of the relationship

and how best to address it are controversial (Fletcher et al. 2012). Furthermore, “the

emotion of shame emerges when a seemingly flawed self is revealed to oneself or others”

(Fletcher et al. 2012). While shame can have adaptive social functions such as solidifying

social roles, evoking sympathy, or appeasing others following the violation of social roles

or norms, it typically serves as a deleterious function in the context of substance misuse

(Fletcher et al. 2012). Shame is more common among those with substance use problems

than those without such problems (Cook, 1987; Dearing et al., 2005), evokes substance

use, and predicts relapse during Alcoholics Anonymous participation (Fletcher et al.

2012). Shame is also the emotional core of self-stigma, which has ben associated with

treatment-seeking delays (Kushner & Sher, 1991), treatment dropout, and poorer social

functioning (Fletcher et al. 2012).

While a variety of substance use treatments address shame in addiction (e.g.

Cook, 1991; Potter-Efron, 2002), none have been systematically evaluated. The

Acceptance and Commitment Therapy clinical trial targeting shame was based “on the

idea that at least two contexts link shame to problematic outcomes such as treatment

dropout, poorer social functioning, and substance misuse” (Fletcher et al. 2012). First,

through a process termed ‘cognitive fusion’, attachment to the literal meaning of self-

critical and self-devaluing thoughts increases the likelihood of destructive behaviors such

as substance use. Second, through a process termed ‘experiential avoidance’—the

tendency to avoid difficult private experiences as a method of behavioral regulation even

when it leads to problems—substances are used to avoid and suppress shame and other

negative emotions (Fletcher et al. 2012). In their hypothesis, Fletcher et al. posit: “If this

is how shame drives problem behaviors in substance use, key treatment targets for shame

should be cognitive fusion with conception of a flawed self and experiential avoidance of

emotions that might otherwise serve as an adaptive role in fostering social repair or

altering destructive behavior patterns” (Fletcher et al. 2012). Thus, in an ACT

(Acceptance & Commitment Therapy) approach, rather than trying to reduce or eliminate

shame, psychological acceptance techniques encourage participants to notice and

experience shame and other difficult feelings more fully, while reducing their conditioned

link to overt action.

“Negative self-judgments like “I’m a loser” or “I am evil” are addressed by

cognitive defusion, noticing the process of thinking, letting go of attachment to

the literal content of thoughts, responding to thoughts in terms of the workability

of behavior tied to them, and then shifting attention toward values-based actions”

Fletcher et al. 2012).

This is very similar to Greenberg & Pascal-Leone’s stage in processing termed dynamic

dialectical construction, marked by positive evaluation. This is produced by first a

progressive unfolding or differentiation of the presenting fear/shame state into both

existential need and a core negative evaluation about the self, and then a dynamic

synthesis of these (Greenberg & Pascal-Leone 2007). When the client begins to move

beyond the experience of shame and fear, a critical moment of constructive abstraction

takes place. Constructive abstraction has been described in cognitive developmental

literature as reading or collating invariances across different types of situations or

contents to create high order truths (Greenberg & Pascal Leone 2007).

After experiencing fear and shame and creating a positive evaluation through

dialectical synthesis of a negative evaluation and an existential need, some clients do not

assert their need but instead directly attend to that need. Self-soothing or self-nurturing is

the affective meaning state that is characterized by fulfilling certain expressed needs

(Greenberg & Pascal-Leone 2007). This serves the same function as assertion, but instead

of directing the emotion outward, it expresses the emotion as tenderness or caring turned

inward toward the self. Prior to creating that positive evaluation, however, self-soothing

and self-nurturing in respect to addiction are often expressed through self-medication.

“According to E. J. Khantzian’s (2003) self-medication hypothesis (SMH), a

psychoanalytically informed theory of substance addiction that considers

emotional and psychological dimensions, substance addiction functions as a

compensatory means to modulate affects and self-soothe from the distressful

psychological states. To manage emotional pain, dysphoria, and anxiety,

substance abusers use the drug actions, both physiological and psychological

effects, to achieve emotional stability” (Khantzian et al. 2008).

Khantzian (1997, 2003) asserted that substance users experience dysphoric emotions as

intolerable and overwhelming and cannot manage these emotional states on their own.

The SMH considers the effects of drugs (e.g. opiates, cocaine, and alcohol) that interact

with the inner states of psychological suffering and personality organization (Khantzian

et al. 2008). For example, alcohol, the most widely abused substance in the United States,

is a central nervous system depressant and features relaxing and sedating effects (Dodgen

& Shea, 2000). “According to Khantzian (1997), alcohol abusers often maintain rigidly

over-contained, constricted emotions. To avoid distressful affects, emotions are isolated

and “cut off” from abusers’ awareness through the use of rigid defenses, leaving the

feelings of emptiness and isolation” (Khantzian et al. 2008). In this retrospective study,

Khantzian et al. hypothesized that the individuals in each drug class would share unique

emotional states, demonstrating that the relationship between the subjective affects and

drug of choice: (a) higher levels of repression and emotional inhibition would predict

one’s preference for alcohol; (b) higher levels of depressive affect or the need to for an

elated psychological state would predict one’s preference for cocaine; and (c) higher

levels of anger or trauma would predict one’s preference for heroin (Khantzian et al.).

Clinical observations showed that specific psychological characteristics are associated

with the drug of choice. This being said, for substance abusers, acceptance and

mindfulness, as postulated both in the Greenberg & Pascal-Leone study and the Fletcher

et al. study, might be adaptive responses to difficult internal experiences such as shame

and negative self-judgment. “Among college students, acceptance has been shown to

moderate the effect of automatic alcohol motivation with drinking behaviors” (Fletcher et

al. 2012).

“The origins of addiction are as varied as the addicts themselves. Each case needs

to be understood as a human faced with a particular set of variables” (Hoffman et al.

2007). Aside from the variables in lifestyle, background, and the particulars that set

substances users apart, “it is well known that stress is a significant risk factor for the

development of drug addiction and addiction relapse” (Dickinson et al. 2011). Though

the cognitive processes involved in the effects of stress on addictive behavior remain

poorly understood, Dickinson et al. propose that stress-induced changes in the neural

circuits controlling instrumental action provide a potential mechanism by which stress

affects the development of addiction and relapse vulnerability (Dickinson et al. 2011).

Consequently, instrumental action can be controlled by two anatomically distinct

systems: a goal-directed system that involves learning of action-outcome associations,

and a habit system that learns stimulus-response associations. Thus, the transition from

initial voluntary drug use to subsequent involuntary, compulsive drug use represents a

switch from goal directed to habitual control of action (Dickinson et al. 2011) and, then

tends to promote reliance on habits. A stressor is a real or interpreted threat to the

physiological integrity of the individual—it triggers behavioral and emotional responses

and leads to numerous physiological changes.

“Many brain systems, including the central dopaminergic and noradrenergic

systems are directly activated by stress. Moreover, stress leads to the activation of

the rapidly acting sympathetic nervous system and the slower hypothalamus

pituitary-adrenal (HPA) axis. Sympathetic nervous system responses include the

release of adrenaline and noradrenaline from the adrenal medulla, which cause,

for example, increases in heart rate, enhanced blood flow to skeletal muscles or

dilation of the pupils and thus prepare the organism for a “fight-or-flight”

response” (Dickinson et. al. 2011).

In addition to glucocorticoids and catecholamines like adrenaline and noradrenaline,

numerous other neurotransmitters, neuropeptides, and hormones are released during

stress, such as vasopressin, substance P, neuropeptide Y, glutamate, or acetylcholine

(Dickinson et al. 2011). “Altogether, these stress-induced changes facilitate the

individual’s ability to face the imminent threat and are generally adaptive. However, if

the stress responses are excessive or prolonged they may promote pathologies, such as

addiction” (Dickinson et al. 2011). They go on to argue, “Acute stress prompts this

switch and may, by these means, increase the risk or relapse to addictive behavior. Lastly,

Dickinson et al. suggest that an aberrant recruitment of habit processes may also

contribute to the enhanced risk of developing drug addiction following periods of

prolonged stress” (Dickinson et al. 2011) This means that in times of perceived crisis or

anxiety, and individual is far more likely to rely on their learned habits, including

substance abuse, to keep themselves functioning, and consequently relapse is much more

likely.

Though it is not clear from their findings whether the use of drugs leads to changes in the

neural circuits underlying goal-directed and habitual action or whether there is a

comorbidity of drug-taking with a genetic or developmental predisposition to habitual

responding, they show that the shift from goal-directed to habitual control of action is

most likely involved in the transition from drug use to drug addiction and in the high

prevalence of relapse to drug use (Dickinson et al. 2011). In addition, given that stress

and glucocorticoids increase dopaminergic transmission, it might be that a dopamine

mechanism mediates the effects of stress hormones on instrumental action. Thus, acute

stress or stress hormone exposure may disrupt the neural systems underlying goal-

directed behavior and promote the reactivation of previously learned, automatic behavior,

otherwise known as habits. During the development of addiction, drug-related habits and

rituals are built up and strong stimulus-response associations are established (Dickinson

et al. 2011; Carter & Tiffany 1999). To conclude this psychoneuroendocrinological

perspective, Dickinson et al. suggest that:

“Although no single factor can predict whether or not a person will become

addicted to a drug and many factors such as availability, genetics, personality,

social environment, or life events may contribute to addiction vulnerability, there

is strong evidence that stress is an important risk factor for the development of

addiction and relapse” (Brewer, Catalano, Haggarty, Gainey, & Fleming, 1998;

Koob & LeMoal 2001; Piazza & LeMoal, 1998; Sinha, 2001, 2008; Dickinson et

al. 2011).

Shame, guilt, sadness, and stress are all crucial emotional and physiological states that

therapies of all forms use to isolate and treat an individual’s addiction. However, the

social environment and self-motivation are equally extremely relevant, though initially

their connection may be elusive. “Motivation has long since been regarded as an

important factor in the treatment of addictive behaviors such as alcoholism and drug use.

It is frequently described as a prerequisite without which the therapist or counselor can do

nothing” (Backman, 1980). Unfortunately, because of the detrimental stigma associated

with addiction in our present society, social anxiety is empirically shown to be a serious

factor in addicts not getting the treatment they need. Furthermore, despite social anxiety

being a relatively common condition, with prevalence rates as high as 40% in some

community samples, it continues to have a massive effect on both the motivation of the

addict to pursue a change in lifestyle, and also on the motivation of an addict to decrease

their tendency to abuse substances in a social context.

“In social situations, socially anxious individuals are posited to expend attentional

resources in monitoring the situation for threat of disapproval or rejection,

focusing on internal representations of “self as viewed by others,” usually

distorting social evaluative information, and causing distress, skill impairment,

and avoidance of further social situations” (Avants et al. 1998).

Use of substances, especially alcohol, to self-medicate social anxiety has been widely

reported, and individuals high in social anxiety have reported decreased self-efficacy for

avoiding the use of alcohol in social situations. Social anxiety has also been linked to

opiate use; opiate use has been hypothesized to serve as a substitute for the activation

endogenous opioid systems posited to occur with normal social relationships (Panksepp,

Herman, Connor, Bishop & Scott, 1978). Moreover, lack of social reinforcement can, in

turn, lead to additional dysphoric states and further self-medication. Socially anxious

individuals have also been characterized as high in persuasibility, conformity, and

submissive behavior, because of fear of negative evaluation, especially from peers,

making them potentially susceptible to the influence of others in their dominant social

network (Avants et al. 1998). A similar study conducted by Acampora et al. saw similar

results, also noting that, “the differences that emerged for social problem severity and

psychiatric symptoms are consistent with findings that the more intensive treatments

produce a greater benefit for clients with severe deterioration and less social stability”

(Acampora et al. 1999) Once a level of treatment was found for a client with the least

amount of social stability and self-respect, but a healthy amount of motivation, the

treatments themselves were far more successful. In addition, the clients with the most

amount of personal motivation were the most successful in ending their addiction. This

reaffirms the crucial need for an addict to have a relationship with society that goes

beyond their addiction, and a desire to be seen as something more than an addict.

However, as Avants et al. noted in their study, “other patients, although not stable, may

have a condition, or personality trait, that conflicts with certain aspects of an intensive

psychosocial treatment program, making them better suited to a less intensive level of

care such as a DTP (Day Treatment Program)” (Avants et al. 1998).

This is further evaluated in a comparative study by Acampora et al. regarding randomized

Day/Outpatient versus Residential Drug Abuse Treatments over 18 month outcomes.

“Extending an earlier report of 6-month outcomes, this study reports 12- and 18-

month follow-up data for clients entering a therapeutic community drug treatment

program who were randomly assigned to day or residential treatment conditions.

Comparisons between groups indicated greater improvement for residential

treatment clients on social problems and psychiatric symptoms but no differences

on the remaining outcomes. Although residential treatment may offer some

specific advantages, the conclusion here is that improvement among day

treatment clients was not significantly different from that of residential treatment

clients” (Acampora et al. 1999)

It is noted both in the Avants et al. study and in the Acampora et al. study that for addicts

who also suffer from larger issues of social anxiety in conjunction with their addiction,

there are presently other successful options in pursuing treatment, and it should be the

informed decision of the addict and their family of not only which decision is most

plausible, but also most successful given the state of the addict. Furthermore, this

matching of one’s addiction with the proper form of care was extensively studied by

Annis et al. in the context of Outpatient Counseling and Client Readiness as they termed

it: “cognitive-behavioral development based change”. As they noted, there is a

widespread recognition in the addictions field that client motivation must be taken into

account in the provision of treatment. Rather than viewing substance abusers as weak-

willed, resistant, or even characterologically flawed, there is an increased acceptance that

motivation varies along a continuum and that most alcohol and other drug abusers

seeking treatment are genuinely ambivalent about change (Annis et al. 1996). Miller and

Rollnick (1991) have suggested that motivation be seen as a “state of readiness or

eagerness to change, which may fluctuate from one time or situation to another” (Annis

et al. 1996). Annis et al. go on to identify the five stages of change in the addiction

treatment field, which coincides with the Simpson and Joe study: precontemplation,

contemplation, preparation, action, and maintenance; and that these stages of change

appear to apply equally to individuals attempting self-change and to those involved in

therapist-assisted change, however, it is the combination of self-motivation with

therapist-assisted change that is the most successful (Joe & Simpson 1993).

Thus, as several studies will and have revealed, an individual without both remedying

social stability and accessing self-motivation, an individual is at a greater risk for

dropping out of treatment early. In a study conducted to test motivation as a predictor of

early drop out from treatment, the authors argue social stability (marital status,

employment, and fewer prior arrests), previous treatment experience, expectations for

reducing future drug use, higher methadone dose level, and higher motivation (Desire for

Help) were identified as significant predictors of treatment retention beyond 60 days (Joe

& Simpson 1993). “DeLeon & Jainchill (1986) have suggested that motivation for drug

abuse treatment is multidimensional and includes how clients perceive intrinsic pressure,

external pressure, readiness for treatment, and suitability of the treatment program (Joe &

Simpson 1993). Three scales were constructed for the study with the intention of

capturing sequential stages of cognitive movement, from recognition to acceptance for

the need for change. They include (1) Assessment of Drug Use Problems, which

measures level of personal acknowledgment (or denial) of behavioral problems resulting

from drug use, (2) Desire for Help, which addresses awareness of intrinsic need for

change and interest in getting help, and (3) Treatment Readiness, which focuses on the

degree of commitment to active change through participation in a treatment program (Joe

& Simpson 1993). “These scales focus on personal appraisals and perceptions by the

individual, representing the cognitive interpretations of numerous external and

environmental pressures (such as legal, family, and peer influences) that often have an

impact on treatment decisions” (Joe & Simpson 1993). Furthermore these scales can be

conceptually regarded as representing progressive levels of change similar to those

described to Prochaska & DiClemente (1986).

“For example, the first scale is related to movement from “precontemplation” to

“contemplation” of change in that it addresses denial of problems as the first

barrier to change. The second scale represents further cognitive movement

towards an “action” stage based on recognition of “hitting bottom”. Finally, the

third scale corresponds more closely with a decision for “action” in the form of

specific commitments to formal treatment” (Joe & Simpson 1993).

In terms of psychological and emotional adjustment findings, a precursor to quitting

addiction for many addicts is the cognitive realization that they have “hit bottom” and

that they need a change in lifestyle. “Client self-ratings of psychological and emotional

adjustment (including descriptions of problems previously caused by drugs) were found

to have the largest correlations to motivation” (Joe & Simpson 1993). Previous research

by Joe, Chastain, and Simpson (1990) also formed confirmatory evidence for this

contention, showing that the primary reasons for quitting opiate use mentioned by a large

majority of opioid addicts were “being tired of the hustle” (83%) and “hitting bottom”

(82%) (Joe & Simpson 1993).

“Addiction is a disease that impacts 1 in 4 families” (Hoffman et al. 2007).

Though the course of an addict’s recovery is extremely personal, the implication on

family and peer relations for treatment engagement is a hugely relevant factor for the

addict’s ability to eventually seek proper care. What’s more, family and peer constitute a

major factor in explaining an individual’s involvement in drug use and delinquency.

“These relationships, however, are only part of what individuals bring with them into

treatment. Also important are an addict’s psychological functions, motivation for

treatment, and level of participation in treatment” (Griffith et al. 1998). In order to more

wholly understand the consequences of family and peer relationships on an addicted

person, and integrative model was proposed to explain deviance and substance use in

terms of 1) the family of origin, 2) perceived peer and family relationships, 3)

psychosocial functioning, 4) motivation for treatment, and 5) treatment engagement

(Griffith et al. 1998). At intake, questions were asked about the degree of support from

parents during childhood. Clients rated each parent on (a) the time spent with client as a

child, (b) sufficiency of parental love, (c) parental warnings about drugs and alcohol, and

(d) perception of parent as a good parent. Composite scales of these four items were

created for mothers and father separately and were labeled poor maternal support and

poor paternal support. Both parental support measures showed good internal consistency.

The measure of perceived family dysfunction at intake assessed perceptions of current

family relations by asking the client to describe time spent together with family members.

Perceptions of family dysfunction was measured and defined by three items: how often

their family (a) helped each other with problems, (b) blamed or fussed at the client about

things, and (c) had disagreements. Perceived peer deviance at intake measured

perceptions of peer relations at the time of treatment admission by asking what the

client’s friends were like and were also defined by three items: whether their friends (a)

sold, dealt, or traded drugs, (b) seemed positive or optimistic about life, and (c) caused

trouble for the client. Clients also completed a self-rating form that assessed

psychological functioning (self-esteem, depression, anxiety, and social functioning (risk

taking and social conformity) as a measurement of poor psychosocial functioning.

Motivation was assessed by the TCU (Texas Christian University) Self-Rating form,

which included three stages of motivation for treatment: drug problem recognition, desire

for help, and treatment readiness. Lastly, treatment engagement was defined by three

measures: individual session attendance, group session attendance, and treatment tenure

(Griffith et al. 1998).

The purpose of this study was to test an integrative model that simultaneously examines

the impact family functioning, peer relations, psychosocial functioning, motivation, and

participation on drug treatment outcomes. The model was tested by using data from

opioid-addicted persons who completed methadone treatment (standard detoxification)

and were interviewed one year after discharge. The hypothesized model was then

designed to fit the data for outcomes at a follow-up. Prior research has suggested that

opioid users typically have poor family and peer relations and come from families in

which they were socially and psychologically deprived (Griffith et al. 1998).

Furthermore, the dysfunctional characteristics of relationships experienced during

childhood are often recreated in the family of marriage—thus the adult family

environment of an addict typically includes the extended family and is characterized by

interpersonal conflict, poor communication, and poor interpersonal boundaries (Griffith

et al. 1998). Individuals with dysfunctional family histories often associate with deviant

peers, and the peer group frequently encourages drug use and criminal activity. Thus, the

study begs the question, “are interpersonal relationships associated with more positive

outcomes, or are more positive outcomes unrelated to relationships with peers and family

members?” (Griffith et al. 1998). Perceptions of childhood family functioning have been

shown to be directly related to adulthood psychosocial functions, additionally, currently

family functioning can predict the degree of a client’s psychological problems

(Costantini, Wermuth, Sorensen, & Lyons, 1992). These findings are important because

high levels of depression and low levels of self-esteem have been found to be related to

increased risk for drug use. (Griffith et al. 1998).

“The results support the hypothesized model examining perceived family and peer

relations simultaneously with psychosocial and treatment process measures as predictors

of opioid use and criminality at follow-up” (Griffith et al. 1998). Essentially, by

encapsulating a multitude of dense factors in this integrative model, Griffith et al. were

able to conclude that both constructs measuring current social relations were reliable

predictors of poor psychosocial functioning. In addition, because information on family

and peer relations, psychosocial functioning, and motivation was collected at the same

time period through self-report measures, the data reflect concurrent client perceptions of

relationships and personal problems.

“On the basis of Prochaska and DiClemente’s (1986) model, these perceptions

may represent the client’s progression past the precontemplation stage. That is,

rather than clients putting on a façade claiming healthy social relations, as is often

done during denial, clients seemed to realize that they had a drug problem and

were indeed involved in unhealthy social relationships” (Griffith et al. 1998).

The findings of this study emphasize the importance of researching what takes place

during the treatment process and confirm that perceptions of peer deviance and family

dysfunction are indirect but important contributing factors toward the level of

participation in treatment. That being said, several researchers have demonstrated the

importance of social relations in the process of addiction and recovery. Specifically,

support from family and friends has generally been documented as having a positive

impact in recovery for drug addicts (Griffith et al. 1998) In addition to improved

outcomes, support during the treatment of addicts has also been associated with improved

process variables such as greater retention, reduced number of drug injections, incidents

of legal involvement during treatment, and may buffer the effects of stress—a key factor

is escalating additive behavior. Because support networks can either have a negative or a

positive effect on treatment outcomes for drug addicts, Griffith et al. suggest that it is

vital for clients to develop healthy social networks by replacing dysfunctional and deviant

ones. “Although this poses a challenging task for clients, social relationships that support

a drug-free lifestyle can facilitate the individual’s ability to cope with the effects of

withdrawal from drugs” (Griffith et al. 1998).

To summarize, the emotional states of shame, guilt, sadness, the physiological

states of stress and fear, and the crucial nature of one’s relationships to their peers and

family are all facets of an addict’s experiences that come together to culminate with a

genetic predisposition and other internal biological factors to create a lifelong battle of

fighting the disease of addiction. Although this battle may have an ever-expanding

number of ailments and therapies, many of which have been discussed here, there is no

one cure, and no one path to success. Within the process of addiction, there are moments

known colloquially as clarity, or “hitting bottom”. These are the moments in which an

addict rises above the challenges they seek to eliminate with substance abuse, and instead

pursues a change in lifestyle. Even still, these crucial moments cannot be identified and

understood through the use of language, which is potentially what makes them so

successful as a mesh of emotional and cognitive starting points. These moments of clarity

and lowest of low points serve as intangible moments of an escape from a series of

otherwise self-destructive synapses and into a place where healthy emotional processing,

and perhaps a healthy lifestyle is still possible.